| U.S. Nuclear Regulatory Commission
Operations Center Event Reports For
08/06/2008 - 08/07/2008 ** EVENT NUMBERS ** |
 | Hospital | Event Number: 44219 | Rep Org: VA NATIONAL HEALTH PHYSICS PROGRAM
Licensee: VA MEDICAL CENTER, PHILADELPHIA
Region: 1
City: PHILADELPHIA State: PA
County:
License #: 03-23853-01VA
Agreement: Y
Docket:
NRC Notified By: EDWIN LEIDHOLDT
HQ OPS Officer: JEFF ROTTON | Notification Date: 05/16/2008
Notification Time: 20:30 [ET]
Event Date: 05/05/2008
Event Time: 09:30 [EDT]
Last Update Date: 08/06/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
35.3045(a)(1) - DOSE <> PRESCRIBED DOSAGE
| Person (Organization):
PAUL KROHN (R1)
HIRONORI PETERSON (R3)
REBECCA TADESSEE (FSME)
| Event Text POTENTIAL MEDICAL EVENT DUE TO USE OF I-125 SEEDS OF LOWER APPARENT ACTIVITY THAN INTENDED
"Notification of a possible medical event per 10 CFR 35.3045 - a brachytherapy procedure in which the administered dose may differ from the prescribed dose by more than 0.5 gray to an organ and the total dose delivered may differ from the prescribed dose by twenty percent or more.
"Permittee: VA Medical Center, Philadelphia, PA
"Event: The event occurred on May 5, 2008, and was discovered on May 15, 2008.
"Description: A permanent implant prostate brachytherapy procedure was performed on May 5, 2008, using I-125 seeds. Seeds of a lower apparent activity than intended were mistakenly ordered and implanted. A CT scan of the patient was performed on May 6, 2008, and a postplan was performed on May 15, 2008. The D90 dose, calculated from the postplan, was less than eighty percent of the prescribed dose. Postplans based on CT scans performed approximately one month after an implant, when swelling from the procedure has partially resolved, are believed to provide more accurate assessment of dose to the prostate. It is intended to obtain another CT scan and postplan at about this time to better assess the prostate dose. The permittee intends to make a determination at that time regarding whether a medical event did occur. The permittee will complete a causal analysis and implement procedural changes to prevent a recurrence before any additional brachytherapy procedures are performed.
"Effect on Patients: The VA is continuing to evaluate this event. At this time, adverse effects to the patient are not expected.
"Patient notification: The permittee is ensuring that the referring physicians and patients were notified.
"Licensee will notify the NRC Project Manager, Cassandra Frasier, of NRC Region III."
* * * UPDATE ON 6/06/08 AT 18:16 EDT FROM LEIDHOLDT TO HUFFMAN * * *
"This is an amendment to NRC Event Number 44219 and is a notification of possible medical events per 10 CFR 35.3045.
"The VHA National Health Physics Program notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.
The VHA National Health Physics Program initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.
Based on a review of other brachytherapy procedures performed between February 1, 2007, and May 31, 2008, the medical center identified an additional four brachytherapy procedures that may be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.
VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.
If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.
VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier).
R1DO (Henderson), R3D(Pelke), and FSME (Chang) notified.
A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient.
* * * UPDATE FROM E. LIEDHOLDT TO JOE O'HARA AT 2009 ON 6/12/08 * * *
"This is an amendment to NRC Event Number 44219 and is a notification per 10 CFR 35.3045 of additional possible medical events.
"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving transperineal permanent seed implant prostate brachytherapy.
"VHA initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional brachytherapy procedures.
"VHA provided an initial update on June 6, 2008. This update reflects the most current information.
"The medical center has identified 45 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were more than 20 percent less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made.
"We note that the medical center prescribes a dose of 160 gray instead of the more common 145 gray and that the number of possible events would be substantially less if the definition of a medical event were based upon the delivered dose instead of a percent of prescribed dose.
"Furthermore, the medical center determines D90 doses from post-implant CT scans performed the day after the procedures. Prostate swelling may cause the doses assessed from these scans to underestimate the delivered D90 doses.
"The permanent implant brachytherapy program has been suspended by the medical center director and an external review will be performed.
"Effect on patients:
"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected.
"Patient notification:
"If these patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.
"Other notification:
"VHA has notified NRC, Region III (NRC Project Manager, Cassandra Frasier)."
Notified R1DO(Summers), R3DO(Louden), and FSME(Mauer).
* * * UPDATE BY E. LEIDTHOLDT TO J. KOZAL ON 6/21/08 AT 1841 * * *
"This is an amendment to NRC Event Number 44219, reported on May 16, 2008, and is a notification per 10 CFR 35.3045 of additional possible medical events. VHA provided amendments on June 6 and 12, 2008. This amendment reflects the most current information.
"VHA notified the NRC Operations Center on May 16, 2008, of a possible medical event at the VA Medical Center, Philadelphia, Pennsylvania, involving a transperineal permanent seed implant prostate brachytherapy procedure of a patient. This patient procedure is now considered to be a medical event.
"VHA initiated a reactive inspection on May 28, 2008. As part of this reactive inspection, the medical center was requested to review additional prostate brachytherapy procedures.
"The medical center has identified 63 brachytherapy procedures that could be medical events because the D90 doses, determined from post-implant CT scans, were 80% or less than the prescribed doses. The procedures are still under evaluation and a final determination has not been made for 60 of these procedures. For three of these 63 procedures including the May 5, 2008, procedure, the D90 doses have been confirmed to be 80% or less than the prescribed doses.
"We note that the medical center routinely prescribes a dose of 160 gray instead of the more common 145 gray and that the number of possible events would be substantially less if the definition of a medical event were based upon the delivered dose instead of a percent of prescribed dose.
"Furthermore, the medical center determines D90 doses from post-implant CT scans performed the day after the procedures. Prostate swelling may cause the doses assessed from these scans to underestimate the delivered D90 doses.
"The permanent implant brachytherapy program is suspended and an external review is in progress.
"Effect on patients:
"VHA is continuing to evaluate these possible medical events. At this time, adverse effects to the patients are not expected. The external review will assess potential medical consequences.
"Patient notification:
"The three patients whose D90 doses were confirmed to be 80% or less than the prescribed doses and their referring physicians have been notified. If other patient procedures are determined to be medical events, the medical center will ensure that the referring physicians and patients are notified.
"Other notification:
"VHA will notify NRC, Region III (NRC Project Manager, Cassandra Frasier)."
Notified R1DO (Schmidt), R3DO (Kunowski), and FSME (Holonich)
* * * UPDATE PROVIDED BY THOMAS HUSTON TO JASON KOZAL AT 1758 ON 6/25/08 * * *
"This report is an update to Event Report #44219. As the result of an ongoing review, a medical event was discovered for a fourth patient on June 24, 2008. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of the event will be sent to NRC Region III."
Notified R1DO (Grey), R3DO (Burgess), and FSME EO (Camper).
* * * UPDATE PROVIDED BY THOMAS HUSTON TO JOHN KNOKE AT 1245 ON 07/02/08 * * *
"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 2, 2008. This brings the total number of medical events to eleven (11) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."
Notified R1DO (Bellamy), R3DO (Kozak), and FSME EO (Zelac).
* * * UPDATE FROM HUSTON TO CROUCH ON 07/08/08 AT 1319 EDT * * *
"As the result of an ongoing review, medical events were discovered for an additional seven (7) patients on July 7, 2008. This brings the total number of medical events to eighteen (18) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these seven (7) additional medical events will be submitted to NRC Region III."
Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).
* * * UPDATE PROVIDED BY LYNN MCGUIRE TO JOHN KNOKE AT 1335 ON 07/09/08 * * *
A 15-day written report of one of the medical events was submitted to NRC Region III.
Notified R1DO (Burritt), R3DO (Duncan) and FSME EO (Burgess).
* * * UPDATE FROM THOMAS HUSTON TO JOE O'HARA AT 0943 ON 7/10/09 * * *
"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional two (2) patients on July 9, 2008. This brings the total number of medical events to twenty (20) under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these two (2) additional medical events will be submitted to NRC Region III.
"We have notified our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."
Notified R1DO(Burritt), R3DO(Duncan), and FSME EO(Burgess)
* * * UPDATE ON 7/15/2008 AT 1213 FROM GARY WILLIAMS TO MARK ABRAMOVITZ * * *
"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional nine patients on July 15, 2008. This brings the total number of medical events to 29 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these nine additional medical events will be submitted to NRC Region III. I will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events."
Notified R1DO (Dentel), R3DO (Lara), and FSME (Burgess).
* * * UPDATE ON 7/18/2008 AT 1313 FROM HUSTON TO HUFFMAN * * *
Bur
"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional three patients on July 18, 2008. This brings the total number of medical events to 32 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these three additional medical events will be submitted to NRC Region III. We will notify our NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events. "
Notified R1DO (Dentel), R3DO (Lara), and FSME (White).
* * * UPDATE ON 7/22/2008 AT 1500 EDT FROM WILLIAMS TO HUFFMAN * * *
"This report is an update to Event Report #44219. As the result of an ongoing review, medical events were discovered for an additional five patients on July 22, 2008. This brings the total number of medical events to 37 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these five additional medical events will be submitted to NRC Region III."
The licensee will notify NRC Project Manager, Cassandra Frazier (NRC Region III), of these additional events.
Notified R1DO (Dentel), R3DO (Riemer), and FSME (Burgess).
* * * UPDATE FROM GARY WILLIAMS TO JOE O'HARA 1145 EDT ON 7/25/08 * * *
"As the result of an ongoing review, medical events were discovered for an additional two patients on July 25, 2008. This brings the total number of medical events to 39 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these two additional medical events will be submitted to NRC Region III. Our NRC Project Manager, Cassandra Frazier (NRC Region III), is aware of these additional events."
Notified R1DO (W.Cook), R3DO (M.Phillips), and FSME (C.Flannery)
* * * UPDATE AT 0805 ON 08/06/08 FROM THOMAS HUSTON TO JEFF ROTTON * * *
"As the result of an ongoing review, medical events were discovered for an additional four patients on August 05, 2008. This brings the total number of medical events to 43 under Event Report #44219. The circumstances involved are similar to those previously reported for this event number. A 15-day written report of these five additional medical events will be submitted to NRC Region III. Our NRC Project Manager, Cassandra Frazier (NRC Region III), is aware of these additional events."
Notified R1DO (Gray), R3DO (D Hills), and FSME (C. Einberg) |
| Power Reactor | Event Number: 44384 | Facility: BYRON
Region: 3 State: IL
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: STEVE GODBY
HQ OPS Officer: DONALD NORWOOD | Notification Date: 08/04/2008
Notification Time: 22:00 [ET]
Event Date: 08/04/2008
Event Time: 18:45 [CDT]
Last Update Date: 08/06/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
DAVID HILLS (R3)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text LOSS OF 84 OF 94 EMERGENCY SIRENS DUE TO INCLEMENT WEATHER
"At approximately 1830, a severe thunderstorm moved through Ogle County. At 1845, 84 of 94 emergency sirens for Byron Station became inoperable. There is currently no estimated time of repair due to the severe number of power outages."
Sirens affected provide coverage for Ogle County (population ~52,000) and a small portion of Winnebago County (population ~296,000). These are utility owned sirens. These sirens are not shared with other sites. In the event of a need for the sirens, a contingency plan using a "route alert" by the state will be implemented.
There are no off-site power or grid concerns.
The NRC Resident Inspector was notified by the licensee. No other state or local government agencies have been notified by the licensee.
* * * UPDATE ON 8/5/08 AT 0321 FROM GODBY TO SNYDER * * *
Troubleshooting and restoration activities continue for the emergency sirens. Presently 73 of 94 sirens remain inoperable.
Notified R3DO (Hills).
* * * UPDATE AT 0645 ON 8/5/2008 FROM STEVE GODBY TO MARK ABRAMOVITZ * * *
At this time, 44 of the sirens are still inoperable. The licensee estimates that all sirens will be operable by 1800 CDT today.
The licensee will notify the NRC Resident Inspector.
Notified the R3DO (Hills).
* * * UPDATE AT 0902 EDT ON 8/5/2008 FROM GREG BALESTRIERI TO MARK ABRAMOVITZ * * *
At 0755 CDT, 55 sirens were inoperable. The licensee will notify the NRC Resident Inspector.
Notified the R3DO (Hills).
* * * UPDATE AT 1258 EDT ON 8/5/2008 FROM GREG BALESTRIERI TO S. SANDIN * * *
At 1155 CDT, 48 sirens were inoperable. The licensee notified the NRC Resident Inspector.
Notified the R3DO (Hills).
* * * UPDATE AT 1713 EDT ON 8/5/2008 FROM GREG BALESTRIERI TO S. SANDIN * * *
At 1500 CDT, 46 sirens were inoperable. The licensee notified the NRC Resident Inspector.
Notified the R3DO (Hills).
* * * UPDATE AT 1933 EDT ON 8/5/2008 FROM JIM LYNDE TO S. SANDIN * * *
Six (6) more sirens have been returned to service. Forty (40) sirens remain inoperable. The licensee notified the NRC Resident Inspector.
Notified the R3DO (Hills).
* * * UPDATE AT 2255 EDT ON 8/5/2008 FROM JIM LYNDE TO J. KOZAL * * *
Seven (7) more sirens have been returned to service. Thirty-three (33) sirens remain inoperable. The licensee notified the NRC Resident Inspector.
Notified the R3DO (Hills).
* * * UPDATE AT 0757 EDT ON 8/6/2008 FROM MARTY WOLFE TO J. ROTTON * * *
As of 0600 CDT on 08/06/08, four (4) more sirens have been returned to service. Twenty-nine (29) sirens remain inoperable with estimate of greater than 24 hours before restoration. The licensee notified the NRC Resident Inspector.
Notified the R3DO (Hills).
* * * UPDATE AT 2345 ON 8/6/2008 FROM BRIAN HERRING TO MARK ABRAMOVITZ * * *
At 2200 CDT 8/6/2008, 17 sirens are still inoperable. The estimated time to repair the remaining sirens is approximately 24 hour.
The licensee notified the NRC Resident Inspector.
Notified the R3DO (Hills) via e-mail. |
| Power Reactor | Event Number: 44386 | Facility: PRAIRIE ISLAND
Region: 3 State: MN
Unit: [1] [2] [ ]
RX Type: [1] W-2-LP,[2] W-2-LP
NRC Notified By: JOHN KEMPKES
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 08/06/2008
Notification Time: 16:47 [ET]
Event Date: 08/06/2008
Event Time: 14:20 [CDT]
Last Update Date: 08/06/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(xi) - OFFSITE NOTIFICATION
| Person (Organization):
DAVID HILLS (R3)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 100 | Power Operation | | 2 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text INADVERTANT ACTUATION OF EMERGENCY SIRENS
"At approximately 1420 CDT on August 6, 2008, a Dakota County Communications Center Shift Supervisor inadvertently activated the Dakota County sirens from the primary unit during conduct of a vendor requested silent siren test. The licensee was notified of the siren activation by the vendor. Seven of the 117 sirens in the 10-mile Emergency Planning Zone (EPZ) were activated for less than one minute. No press release is planned by Xcel Energy."
The licensee notified the NRC Resident Inspector. |
| Power Reactor | Event Number: 44387 | Facility: NINE MILE POINT
Region: 1 State: NY
Unit: [1] [ ] [ ]
RX Type: [1] GE-2,[2] GE-5
NRC Notified By: DON SHEEHAN
HQ OPS Officer: MARK ABRAMOVITZ | Notification Date: 08/06/2008
Notification Time: 21:09 [ET]
Event Date: 08/06/2008
Event Time: 18:40 [EDT]
Last Update Date: 08/06/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(3)(xiii) - LOSS COMM/ASMT/RESPONSE
| Person (Organization):
MEL GRAY (R1)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | N | Y | 100 | Power Operation | 100 | Power Operation | Event Text SAFETY PARAMETER DISPLAY SYSTEM ASSESSMENT LOST
"This 8-hour non-emergency report is being made based upon requirements of 10CFR50.72(b)(3)(xiii) which states, 'The licensee shall notify the NRC as soon as practical and in all cases within eight hours of the occurrence of any event that results in a major loss of emergency assessment capability, offsite response capability, or offsite communications capability (e.g., significant portion of control room indication, Emergency Notification System, or offsite notification system)'.
"At 18:40 ET on Wednesday, August 06, 2008, the Reactor Operator At-the-Controls (OATC) discovered that the Safety Parameter Display System (SPDS) Computer Display was not updating data. This was discovered during periodic Control Room panel walkdowns.
"The last data update on the SPDS display was at 20:02 ET on Tuesday, August 05, 2008.
"All other Plant Process Computer functions are available. Information Technology Department personnel will be investigating the cause of the loss of SPDS capability, which is currently unknown.
"No other Control Room emergency assessment capabilities have been adversely affected. All Control Room panel indicators and annunciators are responding properly."
The licensee notified the NRC Resident Inspector. |
| Power Reactor | Event Number: 44388 | Facility: WATTS BAR
Region: 2 State: TN
Unit: [1] [ ] [ ]
RX Type: [1] W-4-LP,[2] W-4-LP
NRC Notified By: DOUGLAS HOLT
HQ OPS Officer: PETE SNYDER | Notification Date: 08/07/2008
Notification Time: 04:12 [ET]
Event Date: 08/07/2008
Event Time: 02:28 [EDT]
Last Update Date: 08/07/2008 | Emergency Class: NON EMERGENCY
10 CFR Section:
50.72(b)(2)(iv)(B) - RPS ACTUATION - CRITICAL
50.72(b)(3)(iv)(A) - VALID SPECIF SYS ACTUATION
| Person (Organization):
GEORGE HOPPER (R2)
|
| Unit | SCRAM Code | RX CRIT | Initial PWR | Initial RX Mode | Current PWR | Current RX Mode | | 1 | M/R | Y | 50 | Power Operation | 0 | Hot Standby | Event Text TRIP FROM 50% POWER FOLLOWING LOW PRESSURE HEATER STRING ISOLATION
"On August 7, 2008 at 0228 EDT, TVA was reducing reactor power in preparation for a planned reactor shut down. While at approximately 50% power, the feedwater system isolated due to high levels in the low pressure heater strings. Based on the condition stated, the reactor was manually scrammed. All systems functioned as designed in response to the scram. The plant is currently being maintained in Mode 3 Hot Standby condition."
All control rods fully inserted on the manual trip. Decay heat is being removed via auxiliary feedwater to the steam generators steaming to the main condenser. Offsite power is supplying safety buses and emergency diesel generators are available if required.
The licensee notified the NRC Resident Inspector. | |